Coverage Requirements

SECTION SUMMARY:

35+ Body Mass Index (BMI)

Documentation of failed diet attempts

Psychological evaluation

READ THIS FIRST

Even if your insurance company covers bariatric surgery in some plans, that does not mean that your specific plan covers it. The obesity surgery approval requirements in this section assume that weight loss surgery is covered by your specific policy.

Disclaimer: The information contained on this page may not include all components of your insurance company’s medical policy and/or may not be up to date. Contact your insurance company to confirm all benefits.

In order to be approved by Blue Shield California for bariatric surgery in the United States, you must meet the following criteria:

Documentation of active participation in a non-surgical weight reduction program supervised by a registered dietician, healthcare provider (e.g., physician, nurse practitioner), or an organized weight reduction program (e.g., Weight Watchers™, Jenny Craig™), for at least six consecutive months occurring within the last 18 months prior to the request for bariatric surgery

Monthly documentation of all of the following weight reduction program components:

A Note About Weight Reduction Programs

A physician’s summary letter is not sufficient documentation of active patient participation in a non-surgical weight reduction program. Documentation must include medical records and/or diet or weight-loss logs, and assessment of the patient’s progress throughout the programs course.

Bariatric surgical consultation and recommendation by a trained and experienced bariatric surgeon associated with an institution that supports a comprehensive bariatric surgery program, which includes all of the following:

Psychological evaluation and clearance for bariatric surgery

Nutritional evaluation

Long-term monitoring and follow-up post surgery

Adolescents Requirements

BMI > 40.0 with at least one significant obesity-related disease complication which has failed to be controlled with medical management including, but not limited to:

Type 2 Diabetes Mellitus

Hypertension

Heart disease

Obstructive Sleep Apnea

BMI >/= 50.0 kg/m2 with less severe obesity-related complications

Revision Requirements

Revision surgery is considered medically necessary to address perioperative or late complications of a bariatric procedure. These include, but are not limited to:

Staple-line failure

Obstruction

Stricture Non-absorption resulting in hypoglycemia or malnutrition

Weight loss of 20% or more below ideal body weight

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (documented by upper gastrointestinal examination or endoscopy) is considered medically necessary when all of the following are met:

The initial procedure was successful in inducing weight loss prior to pouch dilation

The patient has been compliant with a prescribed nutrition and exercise program

The patient still meets BMI criteria for bariatric surgery

If Your Policy Does NOT Cover It: Seek Partial Coverage

You may be able to get part of the costs paid for by insurance even if weight loss surgery isn’t covered. It’s all about how your doctor and hospital submit your claims to your insurance company.

For example, there are many non-bariatric surgery reasons for your doctor to recommend:

Cardiology exam

Lab work

Medically supervised diet program

Psychological exam

Sleep study

These are ordered for many reasons other than bariatric surgery and may be covered as a result. If your doctor submits one of these claims using a weight loss surgery CPT code (Current Procedural Terminology Code), your insurance is unlikely to cover it. But if your doctor uses a general CPT code, it probably will be covered.

While this may sound “sneaky”, it is an ethical practice. After all, these tests will be beneficial regardless of whether you move forward with surgery.

Contact Blue Shield California to Ask About Bariatric Surgery

Coverage by Plan Type

SECTION SUMMARY:

Coverage Through Your Employer

Individual & Family Plans

Medicare

Before getting into the types of insurance plans, you can cut to the chase by contacting a local bariatric surgeon’s office. Most surgeons will contact your insurance company for free to confirm whether or not you’re covered.

Contact your insurance company directly using the phone number on your insurance ID card

Weight Loss Surgery for Individual/Family Plans

The Affordable Care Act (Obamacare) requires all individual and small group plans (less than 50 full time employees) to include weight loss surgery coverage as long as it is considered an “Essential Health Benefit” in your state.

The following states DO currently consider bariatric surgery an Essential Health Benefit (bariatric surgery is covered by all individual, family and small group plans in these states):

Your State Not on the List?

If your state is NOT on the list, then weight loss surgery is probably NOT covered under your plan.

Bariatric Procedure Cost Compare Tool

Your out-of-pocket bariatric surgery cost can range anywhere from $0 to $20,000 or more depending on several factors, including:

Whether your insurance covers it – many insurances (including Medicare, Medicaid, and many individual/family and employer-provided policies) cover the majority of costs for gastric sleeve, gastric bypass, LAP-BAND®, and duodenal switch. The other types of bariatric surgery are less likely to be covered, although you may be able to get insurance to pay for some of the costs. Tap the “With Insurance” button in the tool to see average out-of-pocket costs per procedure after insurance pays. See our Insurance Tool to find out if your plan covers it.

Which procedure you choose – if insurance won’t pay, costs range anywhere from $8,000 to $20,000+, depending on the procedure. Tap the “Without Insurance” button in the tool to compare the national average self-pay costs for each procedure. (NOTE: Some surgeons offer each procedure for as low as half of the national average).

How competitive your surgeon and hospital fees are – there is often a substantial difference in costs between different doctors and hospitals, even within the same town.

Whether you qualify for tax write-offs – Bariatric surgery is tax deductible, which can have a big impact on the total cost of surgery. You can deduct medical expenses if your out-of-pocket costs are more than 10% of your adjusted gross income. See our Tax Tool to find out if your bariatric procedure will be tax deductible.

How you choose to pay for your procedure – If insurance covers it, you’ll only be responsible for any copays, deductibles, and coinsurance required by your specific plan. If you pay for the procedure without insurance, total costs will depend on how you pay. For example, your surgeon may offer a discount if you pay the full amount up front, and you can make the costs more affordable by applying for bariatric surgery financing.

LOAN ESTIMATOR TOOL

Weight loss surgery is tax deductible, which can have a big impact on the total cost of surgery. You can deduct medical expenses if the costs are more than 10% of your adjusted gross income.

Use the tool to find out if you qualify for a tax deduction.

To receive the deductions, you’ll need to complete Schedule A of the IRS Form 1040. You’ll also need to save your medical bills and payment statements as proof. Money in one of the following special savings accounts (or even your IRA) may also be a way to pay for part of surgery tax-free:

*Disclaimers:Content: The information contained in this website is provided for general information purposes and your specific results may vary depending on a variety of circumstances. It is not intended as nor should be relied upon as medical advice. Rather, it is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician(s). Before you use any of the information provided in the site, you should seek the advice of a qualified medical, dietary, fitness or other appropriate professional. Advertising: Bariatric Surgery Source, LLC has entered into referral and advertising arrangements with certain medical practices, original equipment manufacturers, and financial companies under which we receive compensation (in the form of flat fees per qualifying action) when you click on links to our partners and/or submit information. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Read More